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MARTIN V&WmMM M.©e 




Class j£Dj£2- 
Book_Jd/^ 



Copyright N°- 



COPYRIGHT DEPOSIT 



PLASTER OF PARIS 



AND 



HOW TO USE IT 



BY 



MARTIN W. WARE, M. D. 

Adjunct Attending Surgeon Mount Sinai Hospital ; Surgeon to the Good Samaritan Dis 
pensary ; Instructor of Surgery The New York Posl Graduate School 




NEW YORK: 

SURGERY PUBLISHING COMPANY 

92 WILLIAM STREET 
1906 



l ;\fW 



LIBRARY of OONQRESS 
Two Ooplei Received 
JAN !4 1907 
/ Copyright Entry 

CLASS A XXCmNo. 

/ (o X5s33 

COPY B. 






Copyrighted December, 1906. 
Surgery Publishing Co. 



PREFACE 

The material for the subject-matter of this book is 
based on ten years' -dispensary/ practice in the very large 
joint disease and fracture service (5,000 cases) of the 
Good Samaritan Dispensary. 

The embodiment in book form of this experience and 
of what has heretofore been but a fragmentary consid- 
eration of the subject is due to the suggestion of Dr. 
Walter M. Brickner, Chief of the Surgical Out-patient 
Department, Mt. Sinai Hospital, whose valuable assist- 
ance in editing these pages is hereby thankfully acknowl- 
edged. Thanks are due to Dr. Maurice Green for his 
aid in the preparation of the chapter on Plaster of Paris 
in Dental Surgery. The illustrations are for the most 
part reproduced by Dr. Erwin Reissman from original 
photographs and sketches ; others from standard text- 
books of surgery. 

Martin W. Ware. 
1 198 Lexington Avenue, December, 1906. 



TABLE OF CONTENTS 

CHAPTER I 

The Plaster of Paris Bandage. — Materials. — Manu- 
facture of the Bandage. — Storage. — Bandages of 
Commerce. — Molded Splints. — Protection from 
Soiling. — The Immediate Preparation of the Band- 
ages for Use. — Chemical Adjuvants. — Protection 
of the Skin. — Application and Precautions. — Re- 
moval of the Plaster Bandage. — Replacement of the 
Cast. — Toilet After Bandage is Completed. — Dis- 
posal of Refuse Pages 1-15 

CHAPTER II 

The Application of the Plaster of Paris Bandage to 
Individual Fractures. — Fractures Suitable for Plas- 
ter. — General Considerations. — Posture. .. Pages 16-19 

CHAPTER III 
Fractures of the Upper Extremity. — Fractures of 
One or Both Bones of Forearm. — Fracture of Shaft 
of Humerus. — Fracture of the Elbow Joint. — Colles' 
Fracture. — Fracture of the Thumb. — Fracture of 
the Metacarpal and Carpal Bones. — Time Limit for 
Removal of Plaster Casts in Fractures of Upper 
Extremity Pages 19-24 

CHAPTER IV 

Fractures of the Lower Extremities. — General Rule. 
— Fractures at the Hip Joint. — Plaster of Paris 
Hip Spica. — Fractures of the Femur (Shaft). — 
Fractures of the Lower Half of the Tibia and at 

V. 



TABLE OF CONTENTS 

the Ankle Joint. — Fractures of the Foot. — Fenes- 
trated Plaster of Paris Dressing for Compound 
Fractures. — Methods of Fenestration. — The Am- 
bulatory Plaster of Paris Cast. — Fracture of the 
Patella. — Fracture of the Olecranon Process. — 
Compound Plaster of Paris Splints. — Segmented 
Splints. — Suspended Splints. — Heated Splints. — 

Pages 25-37 
CHAPTER V 

Molded Plaster of Paris Splints. — Methods of Ap- 
plication. — Bavarian Splint. — Hemp Splint. — The 
Tricot Molded Splint. — Cole's Splint. — Braatz 
Spiral Molded Splint. — Molded Splint for Fracture 
of the Forearm. — Gutter Splint Pages 38-53 

CFIAPTER VI 

Plaster of Paris in Orthopedic Surgery. — Plaster of 
Paris Corset. — Vertical Suspension. — Trimming 
the Jacket. — Horizontal Suspension. — Goldthwait's 
Method. — Horizontal Method in Hammock. — The 
Bradford Frame. — Particulars About the Jacket. — 
Lorenz Bed. — Plaster Collar and Jacket. — Torti- 
collis. — Hip Joint Disease. — Application of the Hip 
Spica. — Knee Joint Disease. — Ankle Joint Disease. 
— Flat Foot. — Congenital Hip Dislocation. — Club- 
Foot. — Wolff's Method Pages 54-72 

CHAPTER VII 

Plaster of Paris in Dental Surgery. — Mixing the 
Plaster. — Preparation of the Patient. — Difficult Im- 
pressions. — Making the Plaster Models. — The Sep- 
arating Media Between Impressions and Models. — 
Interdental Splints. — Plaster Models of the Body. 
— Repair and Preservation of Models Pages 73-82 

VI- 



LIST OF ILLUSTRATIONS 

PAGE 

Fig. i. Preparing plaster bandage by hand 2 

Fig. 2. Plaster of Paris cradle 4 

Fig. 3. Plaster bandage ready for use 5 

Fig. 4. Freeing bandage of frayed edges 6 

Fig. 5. Cuff of cotton at the upper and lower limbs 

of the plaster 10 

Fig. 6. Strip of metal incorporated in the bandage. 11 
Fig. 7. Dividing plaster cast with Gigli saws 

placed under the bandage 11 

Fig. 8. Plaster of Paris cast removed in lateral 

halves with mitre or Gigli saw 12 

Fig. 9. Grooves cut in the cast with mitre saw. . . 13 

Fig. 10. Mitre saw 13 

Fig. n. Stilles' shears 13 

Fig. 12. Removing the cast from the limb 14 

Fig. 13. Reapplying the cast with adhesive straps. . 14 
Fig. 14. Plaster of Paris bandage for fracture of the 

forearm 19 

Fig. 15. Plaster cast for lower third of the arm, 

elbow, or the upper third of the forearm. 22 
Figs. 16 and 17. Cast for fracture of the thumb or 

carpal bones 23 

Fig. 18. Metal hip rest 26 

Fig. 19. Pelvis raised on super-imposed fists of as- 
sistant 27 

Fig. 20. Plaster spica of hip 2J 

Fig. 21. Plaster cast for fracture of upper half of 

leg 28 

Fig. 22. Tricot hose investment in fracture of the leg 29 

VII. 



LIST OF ILLUSTRATIONS 



PAGE 

Fig. 23. Assistant holding foot for application of 

plaster bandage 30 

Fig. 24. Patient holding foot for application of 

bandage 31 

Fig. 25. Plaster of Paris splint with two fenestra. . 32 

Figs. 26, 27, 28. Veneering strips to strengthen the 

cast 34, 35 

Fig. 29. Bridging strips of metal permitting motion 

and inspection of the joint 35 

Fig. 30. Wire worked into the two sections of cast 

for suspension 36 

Fig. 31. Molded splint with wire hooks for sus- 
pension 36 

Fig. 32. Illustrated plaster splint with wire for sus- 
pension 37 

Fig. 33- Impregnated plastic fabric applied to the 

forearm 39 

Fig. 34. Molded splint held in place while harden- 
ing 40 

Fig. 35- Splint lined with non-absorbent cotton. ... 41 

Fig. 36. Anterior and posterior splints secured by 

strips of adhesive plaster 42 

Fig. 37. Bandage covering the molded splints.... 42 

Fig. 38. To and fro passage of the plaster of Paris 

roller bandage 43 

Fig. 39. Molding splint for fracture of humerus. . . 44 

Fig. 40. Molded splint for fracture of humerus 

suspended to dry 45 

Fig. 41. Molded shoulder cap, front view 46 

Fig. 42. Molded shoulder cap, lateral view 47 

Fig. 43. Applying sugar-tong splint forearm in 

pronation 48 

Fig. 44. Holding taut the extremities of the sugar- 
tong split 49 

VIII. 



F 





-+;>• 


Fig. 


46. 


Fig. 


47- 


Fig. 


48. 


Fig. 


49- 


Fig. 


50. 


Fig. 


5 1 - 


Fig. 


5 2 - 


Fig. 


53- 


Fig. 


54- 


Fig- 


5?- 


Fig. 


56. 


Fig. 


?7- 


Fig. 


58. 


Fig. 


59- 


Fig. 


60. 


Fig. 


61. 


Fig. 


62. 


Figs 


•63 


Fig. 


65- 


Fig. 


66. 



LAST O/ 7 ILLUSTRATIONS 

PAGE 
Muslin bandage passed around the sugar- 
tong splint 5° 

Braatz's spiral molded splint for Colles 
fracture 5 1 

Posterior molded splint for fracture of one 
or both bones of the forearm. 52 

Plaster of Paris gutter splint for fracture 
of one or both bones of the leg 53 

Application of plaster jacket in Sayre's 
suspension 55 

Plaster of Paris jacket provided with hooks 
for lacing 57 

Plaster of Paris corset with jury-mast in- 
corporated 58 

Application of plaster of Paris corset in 
horizontal position 59 

Application of plaster of Paris corset by 
horizontal method in hammock 60 

Plaster of Paris coronet and corset united 
by steel bands . . . . 62 

Lorenz plaster of Paris bed 63 

Plaster of Paris jacket with figure of eight 
turns about the neck 64 

Plaster of Paris collar 65 

Plaster of Paris coronet 66 

Application of hip spica in the horizontal 
position 67 

Lorenz spica for unilateral congenital dis- 
location 69 

Double spica for bilateral congenital dis- 
location of the hi]) 70 

Wolff's method of redressing club foot. . . 71 
and 64. Dental impression trays y^, 74 

Model of hypertrophied jaw 74 

Model of a syphilitic perforation 75 

IX. 



LIST OF ILLUSTRATIONS 

PAGE 

Fig. 67. Model of a cleft palate 76 

Fig. 68. Kingslev obturator yy 

Fig. 69. Kingslev obturator covering the cleft 78 

Fig. 70. Model of a fracture of the jaw 79 

Fig. 71. Model of a primitive articulation in piaster 80 
Fig. 72. Interdental splint with fenestra for feed- 
ing 81 



X. 



PLASTER OF PARIS AND HOW TO USE IT 



CHAPTER I 
THE PLASTER OF PARIS BANDAGE 

Materials 

The very widespread use of the plaster of Paris band- 
age in hospital and dispensary practice for purposes of 
fixation and immobilization of fractured bones and dis- 
eased joints is in decided contrast to its limited use in 
private practice. An inquiry into the reasons therefor finds 
its best answer in the statement that the plaster of Paris 
bandage found on the market does not usually come up 
to the requirements. Therefore a description of what 
constitutes a properly made plaster of Paris bandage is 
of the first importance. 

The plaster of Paris used in the making of the band- 
age should be of the superior quality used by dentists, and 
the quick-setting kind is to be preferred. It is sold packed 
in tin cans to prevent deterioration (oxidation) by ab- 
sorption of water from the air : and for a like reason it 
must be stored in places free from moisture when once 
the original package has been opened. 

Any one of a number of different fabrics may be em- 
ployed as a substratum in preparing the bandage, such as 
gauzes, crinolin (gauze impregnated with starch), dex- 
trine gauze and flannel. 

The use of plain gauze or muslin is undesirable because 
the plaster sets very rapidly, and becomes too brittle. On 



2 PLASTER OF PARIS AXD HOW TO USE IT 

the other hand, a gauze too rich in starch or dextrine 
will wholly prevent the plaster from setting. The mesh 
of the gauze should be 28x32 threads to the square inch. 
The best kind of gauze is white crinoline without cross- 
bars. 

Manufacture of the Bandage 

The superior plaster of Paris bandage is made by hand, 
for the reason that, made in this way, the right quantity 
of plaster can be incorporated in the bandage. The crino- 




Fig. 1. Preparing plaster bandage by hand. 

line is cut into strips of the widths desired, and loosely 
rolled in ten-yard lengths. One yard at a time being un- 
rolled, a handful of plaster of Paris is rubbed into the 
gauze with the palmar surface of the fingers, so that all 
excess of plaster passes to either edge of the bandage. 
(See Fig. 1.) No more plaster should be rubbed into 
the dextrine gauze than the meshes will hold, and as 
each successive yard is incorporated with the necessary 
quantity of plaster it is loosely rolled in such manner 
that in the center of the bandage there is a hollow cyl- 
inder of the thickness of the finger, and the concentric 
layers are easily movable on one another. This arrange- 
ment permits the rapid and uniform spread of the water 



PLASTER OF PARIS AND HOW TO USE IT 3 

through the bandage, and prevents parts of the bandage 
from being insufficiently moistened. To guard against 
unraveling, a pin should be inserted in the last turn. 

Storage 

The completed bandages should he placed on end and 
sealed in individual tins in the bottom of which a small 
quantity of plaster of Paris is placed, or, likewise ar- 
ranged on end, they may be packed in bulk in large tin 
containers. If the plaster cannot be stored in a dry 
place, it is advisable to wrap each bandage in wax paper 
or gutta percha tissue, newspaper also answers, and, in 
any case, it is a wise precaution to seal the can with a 
strip of adhesive plaster, passed about the overlapping 
edge of the cover. The individual tins or tin containers 
protect the bandages from moisture, and, furthermore, 
permit them to be placed in ovens, as a preliminary to 
using them, in order to drive off any moisture. 

Bandages of Commerce 
A very rigid plaster of Paris bandage has recently been 
put on the market. It is made of exceedingly fine flexible 
aluminum bronze wire netting and is sold in widths of 
one and one-half, two and one-half, three and one-half 
and four inches, in four-yard lengths. It is applied in the 
same manner as the regulation plaster bandage. The 
disadvantages common to the plaster of Paris bandages 
of the shops are that the fabric is not of the dextrine 
order; the mesh is too closely woven — the plaster lies on 
the bandage instead of in the meshes — and as a conse- 
quence, there is an excess of plaster ; the bandages are, 
as a rule, so tightly rolled that the water does not reach 
the deeper layers. These are the bad features of the 
machine-made bandage. It is manufactured by dragging 
the strip of muslin through a compartment filled with 
plaster of Paris, and winding it upon a windlass. (Fig. 

2.) 



PLASTER OP PARIS AND HOW TO USE IT 




Plaster of Paris cradle. 



Molded Splints 

A form of plaster dressing, well adapted to the making 
of molded splints, can be obtained by dipping strands of 
hemp jute (Beeley), flax or straw, of about the width of 
the finger, in a cream of plaster of Paris. This is by far 
the cheapest form of plaster of Paris dressing. Cotton, 
impregnated with plaster of Paris and placed in seamless 
sacks of tricot, constitutes another method of making 
molded splints (Breiger). A modification of the Beeley 
hemp splints consists in placing into a sheath of tricot or 
the leg of a stocking, a bundle of thoroughly beaten hemp 
strands, steeped in plaster cream. This sausage-shaped 
mass is thoroughly kneaded and molded to the parts 
(Turner). Other fabrics like sail-cloth, which contain 
sizing material, are also useful for making molded splints ; 
and I have found the fabric known as "Deimel linen 
mesh" suitable for making molded plaster of Paris splints. 



Protection from Soiling 

Before starting to apply the bandage, the surgeon and 
his assistants should be properly gowned. In every in- 
stance the forearms should be bared, so as to permit the 
greatest freedom of motion in applying the bandage. To 
protect the clothing from being soiled, a rubber apron 



PLASTER OF PARIS AND HOW TO USE IT 5 

or gown should be worn | Fig. 3), or the latter may be 
improvised from a bed-sheet. Either one should extend 
to the collar, and it should he sufficiently long to cover 
the feet, or a pair of rubbers should be slipped over the 
shoes. 

In private practice especially it is also necessary to pro- 
tect the surroundings from soiling by the plaster of 




Fig. 3. Plaster bandage lifted from water, squeezed, and free end 

opened. Manner of handing it to surgeon. (From \Y. VI. 

Brickner's "The Surgical Assistant." By courtesy of 

the publisher.) 

Paris. The floor, the patient's body, and the couch of 
table on which the patient is placed should be covered 
with muslin, gunny sacks, bed sheets or a rubber sheet. 
When these are not available, tar paper, newspaper, or 
ordinary wrapping paper will serve the purpose. 

The Immediate Preparation of the Baxdages for Use 

The number of bandages intended for use should be 
removed from the tin container and stood upon end 



6 PLASTER OF PARIS AXD HOW TO USE IT 

within a foot of the vessel holding the water in which 
they are to be immersed. The tin container, uncovered, 
is to be within arm's reach, in case necessity arise to use 
more bandages. The bandages to be used are to be 
placed to the right and the container to the left. This 
arrangement guards against particles of water being 
spattered upon the bandages still in the container, ren- 
dering them unfit for subsequent use. 




Fig. 4. Freeing bandage of frayed edges. (From W. M. Brickner's 
"The Surgical Assistant." By courtesy of the publisher.) 



The vessel in which the bandages are to be immersed 
should be deep enough to accommodate the widest band- 
age vertically. But one bandage at a time should be im- 
mersed. It is to be placed endw 7 ise in the vessel, which 
contains water as hot as the hand will tolerate. The 
bandage must be completely submerged, and it should 
remain so until the bubbles cease to come ofT. This will 



PLASTER OF PARIS AND HOW TO USE II 7 

take place most readily in the very loosely rolled band- 
ages. The tightly rolled bandages obtained in the shops 
should therefore be unrolled and rendered loose before 
they are wet. When the bubbling has ceased, the bandage 
is lifted out of the vessel, and squeezed with the hand,. 
merely to tree it of the excess of water. In some band- 
ages the edge of the crinoline frays out, and becomes so 
entangled as to hinder the free unrolling of the bandage. 
To prevent this, the frayed out ends should be plucked 
from each side before starting to apply the bandage. 
(Fig. 4.) 

Chemical Adjuvants 

To hasten the setting of the bandage, some manufac- 
turers recommend the addition of salt or alum to the hot 
water. This is not advantageous inasmuch as the band- 
age often sets in the hand before it is unrolled. With 
the home-made bandage prepared, as previously de- 
scribed, with the best quick-setting plaster, the addition 
of chemicals to the water is superfluous. 

Protection of the Skin 

The skin has to be protected from the plaster of Paris.. 
This may be accomplished in various ways. The area to. 
be encased in the plaster of Paris bandage may be wrap- 
ped in cotton wool. The drawback to this is that the 
cotton becomes "caked" and the bandage subsequently 
loosens. Better than this is the use of a flannel bandage,, 
or the "ideal bandage," which is to be applied smoothly, 
without wrinkles and without "reverses," for these are 
apt to exert pressure on the soft parts beneath when the 
weight of the plaster is brought to bear. An elegant in- 
vestment of the skin is afforded by the use of seamless- 
tricot hose, which can be had in various widths and in- 
applicable to the trunk or extremities. For the latter a 
comfortablv fitting sock, stocking, undershirt sleeve or 



8 PLASTER OF PARIS AND HO IP TO USE IT 

drawer leg may be used. When the plaster bandage is 
applied to serve as a cast, the limb need merely be 
anointed with vaseline. 

Application and Precautions 

Xo undue traction should be made in applying the suc- 
cessive turns of the bandage. The use of any other than 
a light hand, when unrolling the bandage on to the mem- 
ber, will be followed by such constriction of the limb 
and interference with circulation, with the setting of the 
plaster, that its prompt removal will probably be re- 
quired. 

In fractures, if the swelling be very marked, if there 
be evidence that the extravasation has not attained its 
maximum, the limb should be elevated and subjected to 
the compression of a rubber bandage, and this should be 
followed by gentle massage, before the plaster bandage is 
applied. On the other hand, it should be borne in mind 
that usually several hours elapse after the injury before 
the surgeon has been called and has made preparations 
to apply the plaster, and generally, therefore, there need 
be no dread of an increased swelling beneath the bandage. 
Indeed, the best means of limiting the swelling after a 
fracture is the prompt application of a plaster of Paris 
bandage. If there be any concern that the plaster band- 
age has set too tight, or will do so, this may be remedied 
in the following manner : AYhile the plaster is yet soft, 
cut through the entire length of the bandage with a pen- 
knife, and with the bandage shears also divide the band- 
age, cotton or tricot, underneath. The subsequent con- 
traction of the plaster in the act of hardening will cause 
a further widening in the furrow made with the penknife, 
and thus relieve the pressure existing. In fact, where 
the circumstances are such that the bandage cannot be 
inspected within the first twenty-four hours after its 
application, it should always be the practice to divide the 



PLASTER OF PARIS AND HOW TO USE IT g 

plaster as described, in order to forestall any possible 
unpleasant developments. 

To guard against a loosening of the plaster of Paris 
bandage, as the furrow widens, strips of adhesive plaster 
may be drawn across the gap to limit it, and then a stout 
muslin bandage applied over the whole plaster dressing. 
Some days later, when the bandage has adjusted itself to 
the underlying parts, and the swelling has subsided, the 
adhesive strips may be drawn tight enough to obliterate 
the furrow and make the bandage fit snugly. 

Marked bony prominences that have to be covered by 
the plaster should be protected with a layer of cotton be- 
fore applying the flannel bandage or tricot hose. As each 
successive turn of the plaster bandage is applied it should 
be smoothed, always in the same direction, by friction of 
the hand, moistened occasionally with water. If the 
bandage be properly made, at no time is it necessary to 
rub in any loose dry plaster, or any paste of plaster that 
settles in the vessel. In fact, this excess of plaster, when 
it sets, adds unnecessary weight to the bandage, and lying 
between the layers of gauze, as it does, and not incor- 
porated with the fibre, it renders the dressing brittle. 
The outer layers of the plaster bandage are apt to chip, 
and these loosened particles irritate the skin and soil the 
garments and surroundings. To obviate this, the finished 
plaster of Paris dressing should be covered the day after 
it is applied with a single layer of dextrine bandage, 
which is moistened and made limp before it is applied, 
but soon becomes dry and hard again. 

The plaster of Paris bandage may be applied to a mem- 
ber in continuity or in sections. In the former method, 
the bandages are wound spirally up and down the length 
of the limb without reverses until each roll of bandage is 
exhausted, and a number of bandages is used to cover 
the same ground until all parts are sufficiently covered. 
In the latter method, the limb is divided off into segments 
and each segment is separately invested with one or two 



io PLASTER OF PARIS AND HO IV TO USE IT 

bandages, according to requirements ; each section of 
plaster overlapping the adjoining one. The former 
method provides a stronger dressing. 

The finished bandage should be exposed to the air to 
effect a thorough hardening. When a hot air apparatus 
is at hand the whole member may be baked for one-half 
hour. 

The upper and lower limits of the plaster bandage must 
not extend beyond _ bandage enveloping the skin. An 





Fig. 5. Illustrating the cuff of cotton at the upper and lower limits of 
the plaster of Paris bandage. 

elegant finish may be given to the edges of a plaster dress- 
ing by turning over its ends, in cuff-like fashion, the ends 
of the flannel bandage. This device must be borne in 
mind while the plaster is being applied, so that the final 
turns of plaster at either end may securely hold in place 
the retroverted fold of flannel bandage. Equally efficient 
in preventing the ends of plaster from impinging on the 
skin is a cuff of cotton held in the grasp of the last turns 
of plaster at either end. (Fig. 5.) 

When the flexure of a joint is encroached upon by the 
plaster, a crescentic section may have to be removed from 
the latter in order to allow free motion of the joint. This 
had better be done while the dressing is in the plastic 
state. Again, with the bandage in the plastic state, it can 
be molded by the pressure of the finger and hands with 
massage-like motions, to conform it to the contour 
of the limb. To bring about an adaptation this molding 
is far superior to, and less dangerous than, the employ- 
ment of traction on the plaster bandage. 



PLASTER OP PARIS AND HOW TO USE IT n 



•I • 


^^"^5^ 




%j: 


•"<> 





Fig. 6. A strip of metal one-half inch wide incorporated in the bandage. 

Removal of the Plaster Bandage 

Some deem it expedient to place a piece of metal one- 
half inch wide (Fig. 6), or a wire, on the limb before 
starting the plaster bandage, and to allow the metal ends 




Fig. 7. Illustration of method of dividing plaster cast with Gigli saws 
placed under the bandages. 

to protrude as a guide where to start cutting the bandage. 
The metal beneath is to qiiard the skin against being cut 



12 PLASTER OF PARIS AXD HOW TO USE IT 

by strokes of the knife. It has also been recommended to 
place a Gigli saw (Figs. 7 and 8) on the limb, before ap- 
plying the plaster. To the protruding ends of the saw 
metal handles are to be attached, and with the aid of these 
the wire is set in motion and the plaster divided from be- 
neath. Even though this saw is constructed of aluminum 
bronze it is liable to corrosion and does not work freelv. 




Fig. 8. Plaster of Paris cast removed in lateral halves, having been cut 
through front and back with mitre or (ugli saw. 

If it is the intention to utilize the plaster of Paris band- 
age again, care must be taken to preserve its integrity. 
This can be best accomplished by cutting a furrow ( Fig. 
9) into the plaster in its entire length with a penknife, or, 
more expeditiously performed, with a mitre saw. (Fig. 
10.) The fabric beneath the plaster constitutes an im- 
pediment to the free motion of the saw and therefore 
gives indication when the plaster is divided, and thus 



PLASTER ()/•' PARIS IND HOW TO USE IT 



13 




Fie;. 9. Showing the grooves cut in the plaster cast with the mitre saw. 

prevents injury to the soft parts beneath. When the 

penknife is used the dropping of acetic acid (or vinegar) 
on the plaster, along the path of the knife, will lighten the 
otherwise irksome task. 




Fig. 10. Mitre saw. 

All complicated devices of the circular saw are useless, 
as the mechanism becomes blocked with particles of 
plaster. 

A very effective instrument for cutting a furrow in 
the plaster bandage are Stilles' shears. (Fig. n.) The 




Fig. it. Stilles shears. 



i 4 PLASTER OF PARIS AXD HOW TO USE IT 

section of bandage removed falls out of the window of 
the cutting blade. These shears are constructed like 
some of the bone cutting forceps, but they are not at all 
serviceable in passing about an angle like the ankle joint. 




Fig 



Manner of removing the cast from the limb. 



After the plaster is divided at every level, the bandage 
beneath is divided with shears. Xow the whole cast may 
be lifted from the limb, much in the manner that a hoop 
is sprung from a barrel (Fig. 12), or by a motion similar 
to the opening of calipers. The flannel bandage is adher- 
ent to the plaster and comes away with it. 




Fig 13. Illustrating manner of reapplying the cast with adhesive straps. 



Replacement of the Cast 

Eventually the cast may be lined with absorbent cotton, 
or the limb invested with another flannel bandage before 
replacing the cast. Straps of adhesive plaster are applied 
circularly over the plaster cast (Fig. 13) and the whole 
recovered with a moistened dextrine bandage. 



PLASTER OF PARIS AND HOW TO USE IT 15 

Toilet After Bandage is Completed 

Such piaster of Paris as may have been spattered on 
clothing, carpets or fabrics had best be allowed to dry 
thoroughly before an attempt is made to remove it. The 

spots on furniture or wood-work had best be removed 
while moist, or if dry. they should be moistened. If not 
much time has been consumed in applying the piaster of 
Paris bandage, and the plaster on the surgeon's hands is 
still moist, it can be readily washed off in warm running 
water. If it be dry. however, friction of the hands with 
granulated sugar will speedily dissolve the plaster. Fric- 
tion with salt will effect a speedy removal by rendering 
the plaster more brittle, and the same may be said of 
ablutions with bichloride of mercury. 

Disposal of Refuse 

The discarded portions of plaster bandage and excess 
of loose plaster should be cast away with household 
refuse. The water used for immersing the bandages 
should be decanted from the plaster paste in the bottom 
of the vessel and emptied into a sink or privy, which is 
then to be flushed with hot water, preferably from the tap. 
Under no circumstances should the paste from the vessel 
be emptied into the waste-pipe, for it is likely to choke 
it up. The paste, if immediately attended to, may be 
loosened by shaking the vessel or by imparting a smart 
blow to it. If this does not suffice, or if the vessel be 
porcelain, the adherent masses may be lifted or scraped 
off with a piece of wood or a knife. The addition of 
water, hot preferably, will aid in loosening the plaster. 
The whole mass is to be thrown away with other house- 
hold refuse or to be incinerated in a furnace. 



16 PLASTER OF PARIS AXD HOW TO USE FT 



CHAPTER II 

THE APPLICATION OF THE PLASTER OF 

PARIS BANDAGE TO INDIVIDUAL 

FRACTURES 

Fractures Suitable for Plaster 

There is hardly a fracture of any bone iri the body 
requiring immobilization, for which the use of the plaster 
bandage has not been advocated. Enthusiasts, indeed, 
would have us use plaster bandages for all fractures. An 
enumeration of the fractures for which the plaster band- 
age is neither desirable nor practical will best show its 
limitations. These are: fractures of the skull (for ob- 
vious reasons) ; of the wrist (Colles) ; of the clavicle; 
of the ribs ; of the shaft of the femur in infancy, in all 
cases, and in adolescence, in most cases. In all other 
fractures the use of a plaster of Paris cast is in place. 
In fractures of the forearm and arm in infants, because 
of the small dimensions of the parts, plaster of Paris is 
always to be preferred to splints. The N-rays readily 
penetrate the plaster, so no objection can be offered to 
its use on this score. Except when applied to the lower 
extremities, its weight can be kept down to that of any 
variety of splint. 

General Considerations 

The immediate use of plaster of Paris for fractures 
does not imply its instant application. L^sually, several 
hours elapse before the bandage is applied ; by which time 
the swelling about the fracture will have attained its 



PLASTER OF PARIS AND HOW TO USE IT 17 

maximum. I i it is desired to reduce this swelling', or 
keep it at its minimum, elevation, massage, the tise of a 
flannel or rubber bandage, preliminary to the application 
of the plaster bandage, will accomplish this. In the use 
of the plaster of Paris bandage, perhaps more so than 
with other sorts of splints, an anesthetic is often required, 
and for the following reason: If the patient be at all 
restless while the deformity is being corrected and align- 
ment maintained, it is very likely that the plaster band- 
age will be put on with undue pressure; and violent mo- 
tions of the patient may crack the quickly-setting plaster. 
If swelling of the lingers or toes or of the extremities 
distal to the bandage should supervene, the immediate 
removal of the bandage is by no means always necessary. 
Before taking this step we should be guided by the color, 
warmth, and amount of pain. If the extremity be cold, 
blue, anesthetic, or extremely painful, and a pulse cannot 
be felt, there should be no hesitancy in the instant loosen- 
ing of the cast by splitting it. On the other hand, if, in 
spite of the swelling, the limb be warm, and not unduly 
red (inflammation excluded), and the accompanying pain 
and throbbing be a source of great discomfort, it is desir- 
able to resort to the expedient of elevating the entire 
member by suspension or by placing it upon cushions, 
and to secure absolute rest by the administration of an 
opiate. If, after recourse to these measures for twenty- 
four hours at the utmost, the pain persists or is w T orse. 
and especially if the warmth of the extremities gives 
place to cold, the cast must be split forthwith. Great 
caution must be exercised when these evidences of cir- 
culatory disturbances — swelling, edema, lividity — mani- 
fest themselves ; for neglect to visit the patient frequently 
may cost him his limb and the surgeon his reputation. 
It need not necessarily follow that the limb becomes gan- 
grenous — a fate just as bad aw r aits a limb encased in 
plaster of Paris, when the patient complains of pares- 
thesia and anesthesia. The undue pressure of the plaster 



i8 PLASTER OF PARIS AND HOW TO USE ET 

of Paris, responsible for these symptoms, will, if not re- 
moved, eause ischemic paralysis, terminating in perma- 
nent eontraetures. A mere splitting of the east in its 
entire length will put an end to all the untoward symp- 
toms just mentioned. 

Under the most favorable circumstances, in the course 
of a week or two, with the subsidence of the swelling" 
the cast may become so loose that it is necessary to re- 
move it, either to pad its interior with non-absorbent cot- 
ton, or to make a thicker investment of the limb : after 
either of which the cast may be replaced. An undue 
amount of perspiration with severe itching, or the pres- 
ence of a solid substance which had accidentally made 
its way beneath the plaster, also demands the removal of 
the cast. 

Posture 

When applying a plaster bandage for fracture, whether 
to upper or lower extremity, the body must be in a re- 
cumbent position. The arm, leg or thigh to be bandaged 
should project beyond the edge of the table and be sup- 
ported by an assistant. It is impossible to apply a plaster 
bandage to the extremities of an infant struggling in 
the arms of its mother or nurse ; nor is the sitting posture 
in an adult conducive to that relaxation of the muscles 
necessary for the proper application of the bandage to 
the extremities. 



PLASTER OF PARIS AND HOW TO USE IT 



TO 



CHAPTER 111 

FRACTURES OF THE UPPER EXTREMITY 

Fracture of One or Both Bones of Forearm 

The patient should be placed on his hack, with the body 
close to the edge of the table, and both forearm and arm 
extending beyond the edge, supported by an assistant. 




4. Application of plaster of Paris bandage for fracture of the 
forearm. 



(Fig. 14.) The deformity is reduced by manipulating 
the fragments, making extension and flexion in the 
antero-posterior or lateral direction, associated with su- 
pination or rotation. The proper alignment accomplished 
fan anesthetic to be administered if necessary), the as- 
sistant grasps the patient's hand, as in the act of hand- 



20 PLASTER OF PARIS AXD HOW TO USE IT 

shaking, making traction and executing counter-exten- 
sion if necessary, or merely supporting the forearm — 
whichever is necessary to maintain the alignment. The 
plaster bandage should extend from the wrist to the flex- 
ure of the elbow. The flannel bandage immediately in- 
vesting the forearm, however, should extend to the heads 
of the metacarpal bones, thus enveloping the hand. The 
fingers are left free. Thus we prevent edema of the dor- 
sum of the hand, and by the color of the fingers we may 
judge of the circulation. If the fracture of the radius 
or ulna, or of both bones, be in the upper third, it may be 
necessary to flex the forearm on the arm. In that event 
the plaster of Paris bandage will include the elbow, and 
must be carried up the arm as far as the fold of the 
pectoral muscle, to secure the right purchase. If the 
bandage on the arm extends only a little above the level 
of the elbow joint or half way up the arm, the weight 
of the plaster bandage on the forearm, by breaking up 
the flexion, will cause the upper part of the bandage to 
press into the soft parts. The flexure of the elbow 
should be well cleansed, dried and dusted freely with 
bismuth subgallate (dermatol), before the bandaging, 
to prevent chafing (dermatitis). 

Fracture of Shaft of Humerus 
In fracture of the shaft of the humerus in its middle 
or lower third, when we are not concerned with the ab- 
duction of the upper fragment, a plaster of Paris dressing 
is suitable. The patient occupies a sitting posture. The 
reduction having been effected, the limb is brought into 
adduction, so that the chest wall forms an internal splint. 
A thin layer of non-absorbent cotton, well ducted on 
both sides with dermatol, being interposed between the 
arm and the chest wall, the arm is held in place by cir- 
cular turns of a muslin bandage, which pass obliquely 
over the shoulder, enveloping it. The forearm is left 
free, so that by its weight, even though supported by a 



PLASTER OF PARIS AND HOW TO USE IT 21 

sling about the wrist, it exerts extension on the lower 
fragment. In the same manner, the plaster of Paris 
bandage envelopes the arm and shoulder, securing them 
to the chest. A layer of cotton wool should be placed 
over the clavicle and shoulder, to prevent pressure by 
the plaster bandage. For infants but one bandage, five 
yards in length, is necessary; for adults, two w r ill suffice. 
The forearm should be snugly wound with a flannel band- 
age, to prevent the development of edema. 

Fracture of the Elbow Joint 

Experience has taught that the plaster dressing is not 
well suited to fracture of the elbow joint, other dressings 
being better adapted. When, however, the plaster band- 
age is chosen, the following steps in its application should 
be observed. The patient occupies a recumbent position, 
and the arm, projecting beyond the edge of the table, is 
supported by an assistant. The forearm is flexed as 
acutely as possible. In the flexure of the elbow joint, 
freely dusted with dermatol, a thin layer of cotton batting 
is placed, and the bony prominences are also enveloped in 
non-absorbent cotton. The arm and forearm, from the 
axillary fold to the wrist, are invested with a flannel band- 
age, and over this, in turn, a plaster of Paris bandage is 
placed. (Fig. 15.) The plaster bandage does not cover 
the upper and lower limits of the flannel bandage. 
These are turned back so as to form a cuff at either end, 
a single turn of the plaster bandage being sufficient to 
secure them. This cuff prevents the edge of the plaster 
from pressing into the skin, and guards against unravel- 
ing of the flannel bandage. 

Colles' Fracture 

In all respects the plaster bandage is to be applied here 
like the cast described for fracture of one or both bones 



22 PLASTER OF PARIS AND HOW TO USE IT 

of the forearm, save that the wrist is included, and the 
bandage is carried down to the heads of the metacarpal 
bones. 

Caution: It is this immobilization of the wrist, how- 
ever, which constitutes a great drawback to the use of 
plaster of Paris in this fracture, for which many other 
devices are far better suited. 




Fig. 15. Plaster cast for lower third of the arm, the elbow, or the upper 
third of the forearm. 



Fracture of the Thumb 



This is the one ringer for which,, if it is fractured in 
any of its parts, a plaster of Paris dressing is suitable. 
Whether the first or second phalanx or the metacarpal 
bone, is fractured, the thumb, in the extended and ab- 
ducted position, is covered with a flannel bandage spica, 
passing in figure-of-eight turns about the wrist, or a 
cotton glove, with the other fingers cut off, is slipped 



PLASTER OF PARIS AND HOW TO USE IT 



23 



over the hand. Either investment is covered with a 
"spica pollicis" of plaster of Paris, including the wrist 
and terminating an inch above it. ( Fig. [6.) As in all 
other casts, the edge of the plaster bandage is covered 
with the last turn of the flannel bandage. 




Fig. 16. Cast for fracture of the thumb or carpal bones. Dorsal view. 

Fracture of the Metacarpal and Carpal Bones 

If the fracture be in the shaft, or near or in the base 
of the metacarpal bones, or in a carpal bone, the hand r 
exclusive of the fingers but inclusive of the wrist and two 
inches of the forearm, is invested with a flannel bandage, 
and this in turn, is covered with a plaster of Paris band- 
age two inches in width. (Fig. 17.) 




Fig. 17. Cast for fracture of the thumb or carpal bones. Palmar view 
showing cuffs of cotton at each end. 



24 PLASTER OF PARIS AXD HOW TO USE IT 

Time Limit for Removal of Plaster Casts in Frac- 
tures of Upper Extremity 

While no general rule can be formulated as to when 
the cast should be wholly set aside in each of the frac- 
tures considered, it should be the practice at the end of 
the second week to remove the cast and inspect the site 
of fracture. This is done to ascertain, not so much the 
extent of union as judged by the wanton practice of 
manipulation to elicit mobility, but rather to note whether 
the alignment is the best possible. For neither a plaster 
of Paris cast nor any other splint is designed to correct 
.any deformity, but only to hold the correctly placed 
fragments in situ. 

When the X-rays are available, and by their use it is 
clearly seen, perhaps on the fluoroscopic screen, but pref- 
erably in radiograms, that the apposition of the frag- 
ments is all that could be desired, we may forego the 
removal of the cast for the purpose of inspection. 



PLASTER OF PARIS AND HOW TO USE IT 25 



CHAPTER IV 
FRACTURES OF THE LOWER EXTREMITIES 

General Rule 
Every cast applied for fracture of the hip, thigh, knee, 
or leg should include the foot in a right-angled position. 
Failure to do this will cause drop-foot (talipes equinus), 
which constitutes a hindrance to walking during the time 
that the cast is in place, and delays walking after its re- 
moval. In neglected instances, indeed, this drop-foot 
requires correction and the application of a plaster cast 
to maintain the proper position. 

Fracture at the Hip Joint 
The use of a plaster cast in fractures of the senile hip 
is indicated only if it is possible to have the patient walk 
about on crutches. Other devices are more effective, but 
at times not applicable, because they necessitate the pa- 
tient assuming a recumbent position for many weeks, 
which is apt to cause hypostatic congestion of the lungs. 
The most effective plaster dressing is that which includes 
the knee and ankle, enveloping the hip in a spica, the 
upper limits of which include the ribs below the mam- 
mary level. 

Plaster of Paris Hip Spica 
The patient occupies the recumbent posture, on a 
kitchen table or a board resting on two horses. The 
pelvis must be well down to the edge of the table, the 
sound limb hanging over the edge and resting with its 
foot on some support. The affected limb is held by an 
assistant, who exerts extension. To prevent the displace- 
ment of the body by the traction efforts, the lower end 



26 PLASTER OF PARIS AND HOW TO USE IT 

of the table may be raised. In addition, a sling made of a 
twisted bed sheet, is passed beneath the crutch (peri- 
neum) and its ends secured to one of the further legs of 
the table, or held by another assistant, to exert counter 
extension. For that part of the dressing which invests 
the lower part of the thigh, the knee, leg and ankle, the 
pelvis may rest flat on the table, but while the turns of 
the spica are applied, the pelvis must be elevated, the 
shoulders remaining in contact with the table. This can 
be accomplished in a variety of ways — by an apparatus 
such as a hip-rest or by improvised devices. Of the 
former, the one here illustrated, made of a band of iron 
bent as shown (Fig. 18), and screwed to a plank, is 




Fig. 1 8. Metal hip rest, screwed to board. 



pushed under the pelvis. The blade supporting the pelvis 
is covered in by the turns of the plaster bandages, but it 
can be easily withdrawn after the plaster has set. Where 
no hip rest is at hand a sling of stout muslin playing 
about a pulley secured overhead, may be used to raise 
the pelvis, the loop of the sling becoming incorporated in 
the bandage. In other instances the pelvis must be sup- 
ported by hands, or on the superimposed fists of an 
assistant (Fig. 19), or an agate ware basin reversed. 
These preliminaries effected, the bony prominences of 
the spines and crest of each ilium are covered with cotton 
batting or pads of piano felt. A flannel bandage now 
invests the foot, leg, thigh, hip, waist and lower thorax. 



PLASTER OF PARIS AND HOW TO USE II 21 





Fig. 19. Pelvis raised on superimposed fists of assistan 



Over this the plaster of Paris bandage is applied. (Fig. 
20.) A narrow strip of piano felt is desirable about the 




Fig. 20. Plaster spica of hip. 



28 PLASTER OF PARIS AX D HO W TO USE IT 

waist to fill out the hollow, for in this situation the spica 
is very likely to crack. This accident may also be 
guarded against by increasing the turns of the bandage 
at that level. The perineum must be particularly guarded 
by proper padding, and if the turns of the bandage hug 
it too closely a crescentic segment must eventually be 
removed to avoid the production of a pressure sore. This 
part, also, must be well dusted with dermatol or talcum, 
and either one of these powders is to be blown in under 
the upper margin and about the pubis, to prevent irrita- 
tion of the skin. That part of the cast in the vicinity 
of the genitals may be coated with shellac so that urine 
or vaginal secretions does not penetrate the cast, render- 
ing it foul and brittle. 

In children, fracture of the neck of the femur is as- 
sociated with adduction of the thigh. Where this diag- 
nosis obtains, the extremity should be put up in a posi- 
tion of marked abduction. 

In children, a plaster of Paris spica may also be applied 
by suspending the patient in a Say re's suspension appa- 
ratus. 

Fractures of the Femur (Shaft) 

The position occupied by the patient is the same as de- 
scribed for fractures at the hip. The cast should extend 
from the gluteal fold, and should include the foot at right 
angles. This form of cast is applicable to fractures in- 
volving the Kxee Joint and for Fractures in the Up- 
per Half of the Leg. (Fig. 21.) 







Fig. 21. Plaster cast for fracture of upper half of leg. Xote right- 
angle;! position of foot, and extent of cast. 



PLASTER OF PARIS AND HOW TO USE IT 29 

Fractures of the Lower Half of the Tibia and at 
the Ankle Joint 

These fractures are so severe and are accompanied 
with such deformity that they necessitate a narcosis to 
make the proper correction. Furthermore, if unattended 
by a wound they are the fractures of the lower extremity 
best suited for the ambulatory cast. 

The patient occupies the supine position. The flannel 
bandage or tricot base (Fig. 22) extends from the con- 
dyles of the tibia, and the lower margin of the patella, 
and includes the foot — which is held at right angles by 
an assistant. (Fig. 23.) The crest of the tibia is cov- 
ered with cotton 
wool to protect it 
from pressure. 
When there is no as- 
sistant to hold the 
foot, a muslin band- 
Fig. 22. Illustrating tricot hose investment in age Sllllg IS paSSeCt 
fracture of the leg. t , ,1 , i.^^ 

about the great toe 
(Fig. 24) and either held taut by the patient, if he be 
conscious, so as to bring the foot at right angles to the 
leg, or the strings of the bandage are fastened to the 
upper end of the table. About the condyles the plaster 
of Paris bandage is to be heavily applied so as to form a 
cuff. 

The cast which is most desirable for fractures at the 
ankle joint differs from the preceding only in the very 
important particular, the position of the foot. 

This variety of fracture is most commonly followed 
by flat-foot. To obviate this it will always be necessary 
to have the foot well inverted (varus) and at a right 
angle to the shaft of the tibia. Thus the patient is made 
to walk on the outer side of his foot. When it is intended 
that the cast should be an ambulatory one, a cuff of plas- 




30 PLASTER OF PARIS AND HOW TO USE IT 

ter should closely hug' the tibia and an extra number of 
turns of plaster of Paris should be passed about the 




Fig. 23. Manner in which assistant holds foot for application of plaster 

bandage. 



lower fourth of the leg, some of them embracing the 
ankle. 

The upper limit of this plaster cast, while it must 
closely embrace the condyles, should not encroach upon 
the popliteal space where it would limit flexion at the 
knee joint. This is avoidable by cutting out a crescentic 
strip of plaster with the penknife while the bandage is 
ret in the plastic state. Other points of pressure in this 
cast are generally encountered on the inner and outer 
aspects of the foot. These are avoided by not carrying 
the turns of the plaster bandage so far forward as to 
impinge on the toes. If these pressure points do give 
trouble, greater relief will be afforded by splitting the 
bandage on either its inner or its outer side, than by 
cutting off any bandage in the circular direction. 



PLASTER OF PARIS AND HOW TO USE IT 31 

Fractures of tup: Foot 

A fracture of any o\ the bones of the foot may be very 
well treated by a plaster of Paris bandage, including the 




Fig. 24. Foot being drawn up at a right angle by a strip of bandage 
held by patient. 



ankle and terminating over the lower third of the leg, 
below the level of the calf. 

Caution: The dorsum of the foot should be well pro- 
tected from pressure by a padding of non-absorbent cot- 
ton. When the metatarsal bones are fractured, a pad of 
piano felt should be placed on the plantar surface as an 
effort to preserve the transverse arch. 



Fenestrated Plaster of Paris Dressing for Com- 
pound Fractures 

This term applies to an ordinary plaster of Paris 
bandage in a part of which a window is cut to permit of 
treating the underlying wound. (Fig. 25.) The open- 
ing in the cast should always be larger than the wound. 



32 PLASTER OF PARIS AND HOW TO USE IT 

Methods of Fenestration 

The window can be made in a variety of ways. 

A. The wound, covered with appropriate dressing, 
may be included in the plaster of Paris dressing. Its 
location having been noted by measurement, a window 
corresponding to its dimensions is then cut from the 
plaster before it has set. The rough edges of the plaster 
bandage can be smoothed and still further protected 
from the discharge of the wound by investing the edges 
with adhesive plaster, or with gutta percha tissue made 
to adhere with chloroform. 

B. The wound, duly protected, is covered with a 
measuring glass, a graduate or a tumbler of convenient 
size, the turns of the plaster of Paris bandage passing 
about the glass. 

The Ambulatory Plaster of Paris Cast 




Showing plaster of Paris splint 
with two fenestra?. 



The treatment of fractures of the leg and particularly 
those of the ankle, 
where there is no axial 
displacement of the 
fragments, demanding 
extension, are best 
suited for the "ambu- 
latory cast." 

It is the practice of some surgeons to have the upper 
limits of the cast at the condyles of the tibia, others 
would include the knee joint. 

The indications for the choice of either may be set 
down as follows : Where the fracture is limited to the 
ankle joint a cast extending to, and embracing the con- 
dyles, is sufficient. All fractures above the middle of the 
leg call for immobilization of the knee also. Under these 
circumstances the cast should be carried up to the gluteal 
fold. 



PLASTER OF PARIS AND HOW TO USE IT 33 

Experience has shown that no metal or wood strips 
need be incorporated in the plaster of Paris dressing. 
The ambulator}- plaster of Paris splint differs from the 
ordinary plaster dressing applied for a like fracture, in 
the extent of the immobilization, in the greater number 
of the plaster of Paris bandages used, and in the inerease 
in thickness of the plaster of Paris bandage by multiply- 
ing the turns at eertain levels. The one situation favored 
by increase in thickness to prevent cracking, is just above 
the ankle joint. The upper limit of the plaster about the 
condyles of the tibia is also increased in thickness so that 
the weight of the body transmitted to the cast will not, 
in being transferred to the knee and thigh, cause the cast 
to cut into the soft parts, as would be the case with a 
thin edge of plaster. The ambulatory plaster splint is 
practicable in a fracture of the ankle or leg without a 
stirrup, by virtue of the mechanical fact that in a pillar, 
the stress and strain are distributed on the surface. 
Hence the column of plaster about the fractured leg car- 
ries, in greater part, the superimposed weight of the body. 
To give some elasticity to the rigid plaster beneath the 
plantar surface of the foot, some authorities advocate the 
insertion of a layer of felt. 

The use of the ambulatory plaster of Paris splint does 
not imply that walking with a fractured limb will be 
possible at once. Only after several days, most common- 
ly at the end of the first week, the patient can make efforts 
at standing and gradually, as he gains confidence, the 
limb can be used to walk with. In course of time the 
plaster of Paris on the sole of the foot softens. This may 
be unheeded, for with the free use of the limb the foot is 
protected with either a felt slipper or an arctic. 

Fracture of the Patella 

In very exceptional instances, where there is so scant 
a separation of the fragments that they can be approxi- 



34 PLASTER OF PARIS AXD HOW TO USE IT 

mated, as estimated by crepitus or the use of X-rays, the 
plaster cast surpasses all other forms of treatment. 

The chief point to be considered in its application, is 
that the turns of the bandage must fit snugly about the 
upper and lower limits of the patella. This can be ac- 
complished best by forcing the bandage down upon the 
patella while it is in the plastic state. Previous to apply- 
ing the cast, approximation may be facilitated by passing 
adhesive straps obliquely about the upper and lower 
limits of the patella. Subsequent to the application of 
the plaster of Paris dressing, a radiograph may be taken, 
to ascertain the relation of the fragments. Inasmuch 
as it is to be the purpose to have the patient to walk 
about, the plaster of Paris cast should include the foot 
in a right angled position. 

If the plaster cast be effective in maintaining the frag- 
ments, it may be removed after the lapse of two weeks, 
to permit of daily massage, and replaced each time. 

Fracture of the Olecranon Process 
This is referred to here for the application of plaster of 
Paris for this fracture corresponds in all essentials with 
its application for fracture of the patella, just described. 

Compound Plaster of Paris Splints 
AYhenever additional material is incorporated among 
the layers of a plaster of Paris bandage, it is termed a 
"compound plaster of Paris bandage.'' These materials 
are incorporated to give additional strength to the band- 
age and incidentally to reduce its weight. 

Strips of veneering 
(Figs. 26-28), tin and 
iron, wire netting and 
gutta percha are the ma- 
terials most commonly 
employed. The metals 
arc least desirable as they Fi s- 26 - stl ^ t] °n theTa^ strips t0 




PLASTER OF PARIS AND HOW TO USE IT y z 



are likely to become rusty, and by this corrosion, break 
and penetrate the bandage. 

In dressing after re- 
sections of the elbow 
and knee, these com- 
|| pound plaster of Paris 
splints find their great- 
est usefulness. (Figs. 

Fig. 27. Veneering strips spirally wound ^ ^_ Q v 
about the cast. 2(3, 2/, 2o. ) 





Fig. 2S. Veneering strips placed the length of the ar 



Segmented Splints 



When it is desirable to have access to the wounds of 
joints (or to wounds 
extending over a 
large part of the cir- 
cumference of an ex- 
tremity), so that they 

may be approached Fig. 29. Bridging strips of metal permit- 
r 11 • -i ,1 ting motion and inspection of the joint. 

from all sides, the 

joint for other surface), is bridged over with bands of 
metal, or with wire, which are incorporated in the turns- 




36 PLASTER OF PARIS AXD HO W TO USE IT 

of the segments of plaster above and below the joint, as 
shown in figures 29 and 30. A sufficient curvature is 
given to the strips so as to permit the joint to have some 
range of motion eventually. 

Suspended Splints 



A strand of wire with hooks may be incorporated in 
any variety of plaster 
splint. These hooks 
facilitate the suspen- 
sion of the limb, as 
may be necessary in 
inflammatory c o n d i- 
tions. (Figs. 30 and 
3i.) ' ! 

A fenestrated splint may also have wire and hooklets 
incorporated in it to permit of its suspension. (Fig. 32.) 




. 30. Wire worked into the two sec- 
tions of the plaster cast to facilitate 
suspension of the limb. 




Fig. 31. (a) Molded splint with wire hooks for 
suspension; (b) the wire itself. 



Heated Splints (Perthes) 



In certain inflammatory conditions of the joints, nota- 
bly in gonorrheal arthritis, in addition to the immobiliza- 
tion effected by plaster of Paris, it may be desirable to 
supply heat to the parts. When this is desired, there may 



PLASTER OF PARIS AND HOW TO USE IT 37 




Fig. 32. Fenestrated plaster splint with wire and hooklets for suspension. 



be wound about the cast coils of rubber tubing, or nar- 
row tubing of lead or of flexible tin. Through this tub- 
ing very hot water is allowed to pass, and is carried off 
into a pail. 



38 PLASTER OF PARIS AXD HO IF TO USE IT 



CHAPTER V 

MOLDED PLASTER OF PARIS SPLINTS 
Methods of Application 

This variety of splint has thus far been but casually 
referred to in the previous pages, It may be made in a 
number of ways. 

Pieces of gauze of several thicknesses, or a single 
layer of flannel, are first cut to the shape of the parts 
(antero-posterior or lateral aspects). They are then 
steeped and kneaded in a plaster of Paris paste. The 
member to be invested is thoroughly anointed with a thin 
layer of vaselin, and covered on both sides with the 
fabric impregnated with the plaster of Paris. (Fig. 33.) 
The latter is held in place by several turns of muslin 
bandage, until it hardens. (Fig. 34.) As soon as the 
setting is completed, the turns of the muslin bandage are 
divided, and the splints are set aside, to dry still further, 
if possible. They are then lined with non-absorbent cot- 
ton. (Fig. 35.) When applied, the splints are to be 
held securely in place by circular turns of adhesive 
plaster, one near each extremity of the splint and the 
other fastened in the center. (Fig. 36.) The two splints 
are then covered with a gauze or muslin bandage (Fig. 
37), and this, in turn, is covered with a crinolin bandage, 
which prevents shifting of the splints. 

The advantages of this variety of splint over the cir- 
cular plaster of Paris bandage, consist in its lightness of 
weight, and the ease with which it can be taken off and 



PLASTER OF PARIS AND HOW TO USE IT 



39 



put back again, so as to enable inspection and to better 
the reduction of the fragments, if necessary. 

Instead of impregnating the layers of gauze by steep- 
ing and kneading them in the cream o\ plaster, the latter 
may be poured on the gauze from a pitcher, and rubbed 
into the meshes with the hand. The impregnated gauze 




Fig. 33. The impregnated plastic fabric applied to the forearm. 



is then applied as in the previous method. This is a 
rather messy procedure. 

A third manner of preparing molded splints is directly 
from a plaster of Paris roller bandage. A bandage of 
the desired width having been selected, it is cut in the 
necessary lengths, ascertained by measurement. To pre- 
vent the crinolin from curling up, a weight is placed 
upon either end. Warm water is then allowed to drip 



40 



PLASTER OF PARIS AND HOW TO USE IT 



on the several superimposed layers of gauze, to saturate 
them. They are then applied to the limb and molded in 
the same manner as described in the first method. 

Again, the plaster of Paris roller bandage, having first 
been made plastic by immersion, may be cut in lengths to 
correspond to measurements of the extremity. Several 




Fig. 34. Molded splint held in place while hardening 



such lengths are superimposed and then molded on the 
limb as described. 

Finally, the moistened plaster bandage may be directly 
molded on the limb by playing the bandage to and fro 
upon it, each end of the bandage being held by an assist- 
ant, who grasps the successive turns as they are superim- 
posed (Figs. 38, 39, 40), the surgeon at the same time 
stroking the bandage to make it adhere to the deeper 



PLASTER OF PARIS AND HOW TO USE IT 



4i 



layer. The subsequent steps arc identical with those 
mentioned above. 

The Bavarian Splint 

This variety of molded splints is made as follows: 
Two pieces of canton flannel, shaped to conform to the 
circumference of the fractured member, are sewn together 




Fig. 3^. Splint lined with non-absorbent cotton. 

lengthwise through their middle, in single or double line 
of stitches, the seam always arranged to occupy the pos- 
terior aspect of the limb. One-half of the inner layer of 
flannel is then passed about the limb and secured, by sev- 
eral stitches or by adhesive plaster, to the underlying 
dressing (bandage). Plaster of Paris paste is then ap- 
plied, and thoroughly rubbed into this layer of flannel. 
Before the plaster has dried the outer layer of flannel 



42 PLASTER OF PARIS AND HOW TO USE IT 





'■nWTTl" ' ' ' 




\W^M 


■""■"' y% 






^HH^I ^i^"^" : ^^f^ 1 ^ 


1 Hi 

f 

L Jm 



Fig. 36. Anterior and posterior splints secured by strips of adhesive 

plaster. 



I H 

■ - A, 


a 






' r -■■^y^.sr-; :? : 


$£r 






BL""* " "' Jf 


|:'-'llit. 


W- 


^"Jgll 


^| 




^ 


11 



Fig. 37. The bandage covering the splints. 



PLASTER OF PARIS AND HOW TO USE IT 



43 



on the same side, is superimposed. The two flannel layers 
on the other side are then similarly manipulated. When 
both halves have set completely, they may be cut down in 
front, and turned to either side, the seam posteriorly 
acting as a hinge, to permit of an inspection of the parts, 
after which they are turned back again and securely held 




Fig. 38. To an 1 fro passage of the plaster of Paris roller bandage. 

in place with several strips of adhesive plaster, over which 
turns of a muslin bandage are passed. 



Tin-: Hemp Splint 

This i.^ another form of molded plaster of Paris splint 
A number of strands of hemp are beaten, then dipped 
into a paste of plaster of Paris and spread out over the 
limb, previously anointed with vaselin. Additional plaster 
of Paris paste is rubbed into the strands of hem]), and 



44 PLASTER OF PARIS AND HOW TO USE IT 

more of the latter are added, from time to time, to im- 
part the necessary thickness to the splint. First an an- 
terior, and then a posterior, section is molded, and both 
are held in contact with the limb by turns of a muslin 
bandage. The latter is divided when the splints have 
hardened, and these are now lined with non-absorbent 




Fig. 39. Molding splint for fracture of humerus. 

cotton and securely held in place by strips of adhesive 
plaster and a muslin roller. 

The Tricot Molded Splint 

A length of tricot cylinder is filled with cotton or, 
preferably, strands of hemp. It is then dipped in the 



PLASTER OF PARIS AND HOW TO USE IT 45 

paste of plaster and thoroughly kneaded therein. When 
completely impregnated, it is applied to the part and 
shaped to it by turns of a muslin bandage, which holds 




Fig. 40. Molded splint for fracture of humerus suspended to dry. 

it in place while it is hardening. Like the other splints, 
it is subsequently lined with non-absorbent cotton. 



Molded Splint for Fracture of the Shoulder ok 

Arm 

This splint should be made to extend from the root of 
the neck to the elbow and to embrace the arm on all but 



46 PLASTER OF PARIS AXD HOW TO USE IT 




Fig. 41. Molded shoulder cap, front view. 



PLASTER OF PARIS AND HOW TO USE IT 47 




Fig. 42. Molded shoulder cap, lateral view. 






48 PLASTER OF PARIS AND HOW TO USE IT 




Fig. 43. Applying sugar-tong splint, the forearm in pronation. 



PLASTER OF PARIS AND HOW TO USE IT 



49 



its mesial side. ( Figs. 41, 42.) With the aid of such a 
molded splint, we can attain complete immobilization 

when the splint is secured to the thorax with muslin and 




Fig. 44. Holding taut the extremities of the sugar-tong splint. 

dextrin bandages. The elbow being" left free, it may act 
with the forearm as a counterextendino- factor. 



Cole's Splint. Fracture of the Forearm 
Here we may use an anterior, a posterior splint ( Figs. 
43 and 44), or, as in the "sugar-tong splint" of Cole, 
one piece hinged at the elbow. This latter splint is made 
by passing a plaster of Paris bandage from the wrist 
along the flexor aspect of the forearm, the latter being 
held in a position of pronation (Fig. 43), and then, turn- 
ing about the elbow, the bandage covers the extensor 
surface of the forearm. The extremities of the bandage 



50 PLASTER OF PARIS AND HOW TO USE IT 




Fig. 45. Muslin bandage passed around the sugar-tong splint. 



PLASTER OF PARIS AND HOW TO USE IT 51 

are held taut by the surgeon while it is setting. I Fig. 

44.) The dressing is held in place by turns of a muslin 



Braatzs Spiral Molded Splint 

This bandage is suitable for fractures in the lower por- 
tion of the forearm or Colles 1 fracture. A strip of gauze 
impregnated with plaster of Paris paste, or tricot cylinder 
rilled with plaster paste, is wound spirally about the 
forearm, beginning at the elbow, just beneath the inter- 
nal condyle, then, pass- 
ing obliquely over the 



flexor surface of the 
forearm, it turns about 
the radial side of the 




Fig. 46. 



Braatz's spiral molded splint 
for Colles' fracture. 



torearm, passing over 
the lower third of the radius on its dorsal surface, and 
terminates at the head of the metacarpal bones. (Fig. 
46.) The splint is finally lined with non-absorbent cot- 
ton and covered with turns of muslin and starch band- 
ages. 



Molded Splint for Fracture of the Forearm 



Several layers of crinolin, of appropriate length, are 
dipped into a paste of plaster of Paris, and are then 
applied to the dorsum of the forearm, from the elbow- 
to the heads of the metacarpal bones. The forearm is 
allowed to rest on the thigh (Fig. 47), and if the fracture 
be in the lower end of the radius or ulna the hand is 
sharply flexed at the wrist, grasping the knee. Before 
applying the splint, the arm is anointed with vaselin, 
in order that the mold may be easily removed after it 
has set. The splint is then lined with non-absorbent cot- 
ton, dusted with dermatol ; and secured to the forearm. 



52 PLASTER OF PARIS AND HOW TO USE IT 

first by adhesive straps one inch wide, then by muslin 
bandages, and lastly by a crinolin bandage. Instead of 
the layers of crinolin, a roller bandage of plaster of 
Paris, the width of the forearm, may be run up and 
down, and molded to the shape of the limb. 




Fig. 47. Posterior molded splint for fracture of one or both bones of the 

forearm. 



Gutter Splint 



This splint is molded, in the same manner as the one 
just described, about the foot, which is to be in the right- 
angled position. It extends up the calf of the leg to the 
flexure of the knee joint or above. (Fig. 48.) It is 
suitable for fracture of the leg or injuries of the knee- 
joint, when ambulatory treatment is deemed inadvisable. 



PLASTER OF PARIS ASH HOW TO USE IT 53 

It is not eligible when there is any deformity, for the 

splint embraces but half the inner and outer aspects of 




Fig. 48. Plaster of Paris gutter splint for fracture of one or both bones 
of the leg. 



the leg'. When dry, the splint is lined with non-absor- 
bent cotton dusted with dermatol. and held in position 
by muslin and crinolin bandages, applied successively. 



54 PLASTER OP PARIS AXD HOW TO USE IT 



CHAPTER VI 

PLASTER OF PARIS IN ORTHOPEDIC SUR- 
GERY 

Plaster of Parts Corset 

It was this device as taught by Sayre that gave the 
greatest impetus to the use of plaster of Paris dressings. 
The manner of its application laid down by him survives 
to this day as the chosen method. A plaster of Paris 
jacket may be applied with the patient either in the sus- 
pended vertical position (Sayre), or in the swaying hor- 
izontal, or recumbent position. 

Vertical Suspension. — The patient is stripped of all 
clothing. The body is cleaned with soap and water, rubbed 
with alcohol, and freely dusted on all sides with talcum, 
dermatol, bismuth, or a mixture of these. While in a 
position as if crawling, /. c., with the body's weight sup- 
ported on the hands and knees, a seamless shirt or tricot 
hose is slipped on. If the latter is used, the upper end is 
fitted by slitting the hose in the axillary lines to a depth 
sufficient to bring the ends over the shoulder, where they 
may be tied, or secured with a few T stitches or a safety- 
pin. All folds in the shirt are smoothed away by drawing- 
it down and securing it snugly in the perineum with a 
safety-pin. The patient is lifted, with assistance if heavy, 
into the suspension apparatus of Sayre ; for with a dis- 
eased spine, the patient should never assume, unsupported, 
the erect posture. The patient is suspended in the ap- 
paratus by the chin, with the arms extended and grasp- 
ing the cross-bar to aid in the extension of the spine. 
(Fig. 49.) The ropes that are fastened to the cross-bar 
and play about the pulleys above, are drawn upon until 



PLASTER OF PARIS AND HOW TO USE IT 55 

the entire body sways, and the tips of the toes touch the 
floor, or the stool placed beneath so that the patient's 
trunk is on a level with the arms of the surgeon seated 
and applying the plaster bandages. An assistant grasps 
the legs to prevent the swaying of the bod)', as well as 
its rotation, and to gfuard against the inadvertent flexion 




Fig. 49. Application of plaster jacket in Sayre's suspension. 



of the thighs. Another assistant controls the rope with 
one hand, and with the other steadies the extended arms 
of the patient, so as to prevent rotation of the cross-bar. 
All the bony prominences, such as the spines of the 
ilium, and the gibbus itself, and also any very decided 



56 PLASTER OP PARIS AND PLOW TO USE PT 

hollow, especially about the waist line — if there be much 
lateral curvature or lordosis — are covered with a thick- 
ness of piano felt. This is to protect the prominences 
from pressure, and to fill in the hollows, so that the sym- 
metry of the jacket may prevent the plaster from crack- 
ing. In each axilla felt or several thicknesses of gauze 
will protect the skin from the friction of the edges of the 
finished jacket. These pads are successively placed as 
the turns of the bandage are about to grasp them. It 
is no longer the practice to place a pad over the gastric 
area to make allowance for the full or empty stomach. 

If the patient rests comfortably in the suspended posi- 
tion, the application of the plaster of Paris bandages may 
follow. The bandages should be four inches wide for the 
younger children, and for older children, of larger build, 
six inches. The bandages are passed circularly around 
the body. Below, the bandages should reach the great 
trochanters, and above, they should pass under the axilla 
and well over the top of the sternum. These limits of the 
jacket must be well borne in mind; for the commonly 
committed failure to observe them is chiefly responsible 
for ill-fitting corsets. If too short below, the jacket 
presses into the abdomen, or the latter bulges out beneath 
the edge of the plaster ; if not carried high enough, the 
jacket fails to effect the necessary extension of the spine. 
After the setting of the plaster is completed the patient 
is to be lifted out of the swing. Being grasped by an 
assistant from behind, his hands passing beneath the 
axillae, the patient is borne on the chest of the assistant, 
and is placed, temporarily, in the recumbent position. 

Trim 111 in g the Jacket. — In order to allow flexion of 
the thighs on the abdomen a crescent of plaster of suffi- 
cient size is removed from each side, at the level of 
Poupart's ligament. To allow adduction of the arms a 
crescent-shaped piece is cut from the axillae. The band- 
age must not be cut below the sternal notch, and a tongue 
of plaster must be left about the symphysis pubis. The 



PLASTER OF PARIS AND HOW TO USE II 



57 



jacket must be cut on the sides until it conforms to the 
upper limit of the great trochanter. The patient now 

assumes the crawling attitude and the jacket is trimmed 
above, straight across posteriorly from the upper limit of 
one axillary fold to that of the other. Below, the excess 
of plaster is cut across posteriorly at such a level that the 
cast will not touch the chair seat when the patient is sit- 
ting. If there be any sinuses leading into old abscesses, 
the cast should be fenestrated, to admit of their being 
dressed. Any small decubitus (pressure sore) which is 
likely to form over the gibbosity may be dressed with 
balsam of Peru under the jacket without fenestration. 

The shirt or tricot hose extending beyond the cast is 
drawn back over it and stitched together. This excess of 
hose not only imparts a neat finish to the jacket, but 
also prevents the rough cut edges of the plaster from 
pressing into the soft parts. When an excess of shirt 
or tricot is not available, the cast may be covered with 



m 




Fig. 50. Plaster of Paris jacket provided with hooks for lacing. 



58 PLASTER OF PARIS AND HOW TO USE IT 



several turns of a crinolin bandage, and the cut edges 
covered with adhesive plaster. If the cast is to be a 
permanent one, it is now completed. If, however, it is 
to be a removable one it is to be cut down the front with 
a mitre saw or Stilles' bone forceps while the trimming 
is being done. The opposing front edges thus formed 
are bound with adhesive plaster and are fastened to- 
gether with the same material. For long-continued wear, 
the edges should be bound with leather or canvas pro- 
vided with a row of hooklets. These are stitched on and 
laces thrown about them. (Fig. 50.) 

Jacket with Jury-Mast. — For the cervical form of 
Pott's disease, it is customary to incorporate a jury-mast 
in the dorsal part of the jacket. This latter device (as 
illustrated in Fig. 51), is a band of steel, its lower end 
having pieces of tin attached at right angles to facilitate 
its fixation in the plaster cast. It is bent to conform to 
the spine, and passes over the occiput to the vertex of the 




Fig. 51. Plaster of Paris corset, with a jury-mast incorporated. 



PLASTER Of PARIS AND HOW TO USE IT 



59 



skull. At this point there is attached a short bar which 
plays on a pivot. From either end of the bar there 
passes a piece of webbing or leather strap around the 
chin to support the head, 'idle band of steel should be so 
bent as not to touch the spine or the head. The degree 
of extension will he the greater the more the steel band 
is carried away from the head. 

Horizontal Suspension. — When a suspension apparatus 
is not at hand, the patient may be placed in the horizontal 
position, face down, the body being stretched between 
two tables. (Fig. 52.) The shoulders rest on a pillow 




Fig. 



Application of plaster of Paris corset in horizontal position. 



on one table, and the thighs on another. ( )ne assistant 
is detailed to apply traction to the thighs, and another, 
hooking his fingers in the axilke, exercises traction up- 
ward. The weight of the trunk effects a lordosis, there- 
by overcoming any tendency to kyphosis. The same 
precautions are to be observed as in the vertical method, 
in covering any bony prominences. The plaster bandage 
is passed in circular turns around the trunk. 



6o PLASTER OF PARIS AND HOW TO USE IT 

Goldthwaifs Method. — A jacket may also be applied 
with the patient in a recumbent position, resting upon an 
appliance consisting of two wire supports, on one of 
which rests the sacrum, the other being placed beneath 
the deformity (with pads intervening). With hyper- 
extension, a sufficient leverage is exerted to correct the 
deformity. The plaster bandage passes about the sup- 
ports and includes the pads. 

Horizontal Method in Hammock. — In place of the 
tables, again, a hammock made of extra stout muslin or 
canvas is suspended between two chairs, or two wooden 
horses, or over the ends of a bed. The patient is placed 
therein, face downwards, arms and legs extended. The 
plaster of Paris roller bandage, in its turns about the 
body, includes the hammock. On the completion of the 
bandaging, the excess of hammock is cut awav. (Fig. 
53-) 





Fig. S3- Application of plaster of Paris corset by horizontal method in 

hammock. 



The Bradford Frame is similar in application to the 
hammock. It is a rectangular frame constructed of gas 
pipe, over which is stretched a piece of canvas. The 
patient rests on this, face down, arms extended, the 
hands grasping the frame above, while the feet may be 
drawn down by an assistant ; or each foot, with the 



PLASTER OF PARIS ASH lIOiT TO USE IT <>i 

thighs in the abducted position, may be secured, with 

traction, to the lower part ^i the Erame. A slit is then 
cut in the canvas on each side ^\. and parallel with, the 
body. Through these slits the roller bandage passes in 

its turns about the body, to include the canvas bed. The 
excess of canvas is cut away after the bandaging is com- 
pleted. 

Particulars About the Jacket. — The jacket should 
weigh between one and two pounds, and should be of 
uniform thickness throughout. If there is any decided 
acuity of the symptoms it is far better not to split the 
jacket, lest meddlesome guardians remove it too fre- 
quently. A well-fitting and comfortable jacket may re- 
main in place for two months. At the expiration of this 
time the condition of the skin demands consideration, and 
the removal of the jacket is necessary for hygienic 
reasons. Thereafter it may be provided with hooks and 
laced, or brought together with strips of adhesive plaster, 
and so held in place. 

A laced jacket is indicated in the less acute cases of 
spondylitis, and where extensive wounds require surgical 
dressing. Jackets are also indicated in cases of lateral 
curvature to supplement gymnastics, and for cases in 
which the distorted spine is painful. A plaster of Paris 
corset is also indicated in fracture of the spine prior to 
the performance of an operation, or when operation is; 
contraindicated : and also after an operation has effec- 
tually reduced the fracture. In some very exceptional 
cases of rachitic curvature I have also applied a jacket 
with benefit, for it prevented the movements of a very 
tender spine until anti-rachitic treatment became effective. 

It may at times be necessary to extend the plaster 
bandage so as to include the hip in a spica, as in sacro- 
iliac disease, or in a complicating hip-joint affection; and 
if the spinal disease be in the upper cervical region the 
turns of the plaster bandage should even pass about the 
shoulders so as to carry them well back. 



62 PLASTER OF PARIS AND HOW TO USE IT 

The report of any pain, or the existence of any odor, 
about the jacket is indicative of an open wound. This, 
in the case of children, is commonly caused by the ex- 
istence of a foreign body, playfully inserted or accident- 
ally finding its way beneath the jacket. 

A plaster jacket may be employed as a mold, from 
which, by filling the interior with a mixture of plaster of 
Paris, a cast of the deformity can be made. Over this 
cast corsets of other material — felt, wood, veneering, 
aluminum, and celluloid — may, in turn, be molded. 

If a jury-mast be not obtainable, a crown of plaster of 
Paris may be passed about the head and this then joined 
by two steel bands passing to the plaster jacket and in- 
corporated in its turns. (Fig. 54.) 



£* 




Fig. 54. Plaster of Paris corset and coronet united by bands of steel. 
Suitable for immobilization of the spine or for torticollis. 



PLASTER OF PARIS AND HOW TO USE IT 63 
Lorenz Bed 

In young infants who are to be carried about, a plaster 
jacket is impractical because of its weight, and because 
it impedes the thoracic movements. As such infants do 
not assume a sitting or an erect posture, they are best 

treated in recumbency. For this purpose the Lorenz 
bed is admirable. (Fig. 55.) It is a splint molded to 




Fig. 55. Asterisks denote the Lorenz plaster of Paris bed for tuberculous 
spondylitis. 

the contour of the spine, extending laterally to the pos- 
terior axillary line. When the disease is in the upper 
spine, it may be molded about the neck and head. It is 
to be padded with non-absorbent cotton, and secured to 
the trunk bv turns of muslin and crinolin bandages. 



Plaster Collar and Jacket 

When the disease of the spine is high up in the dor- 
sal region, or in the lower cervical, the bandages may be 
extended around the neck (Fig. 56) in figure-of-eight 
turns ; or by like turns the head may be fixed ; or a sep- 
arate collar (Fig. 57) may be made, impinging upon the 
mastoid processes embracing the lower jaw, extending 
well onto the shoulders, and resting upon the clavicles. 
These plaster investments for the neck are indicated in 
the correction of torticollis, or after resection of the 



64 PLASTER OF PARIS AND HOW TO USE IT 

sternomastoid for spasmodic torticollis, and for fracture 
of the cervical spine. 




Fig. 56. Plaster of Paris jacket with figure-of-eight turns about the neck 

for cervical spondylitis or torticollis. 



Torticollis 

During the period of time, when non-operative meas- 
ures are resorted to, in the hope of correcting wry-neck, 
the deviation of the head dependent on congenital spastic 
contraction of the sterno-mastoid muscle, may be over- 
come by suspension in the Sayre's apparatus. Where 
this can be accomplished, the position may be maintained 
by investing the body with a plaster of Paris jacket of 
light construction and extending it so as to pass about 
the neck in figure-of-eight turns (Fig. 56) or, if the 



PLASTER OF PARIS AND HOW TO USE VI 65 

muscle be more unyielding, the plaster of Paris should 
also include the head, encircling the occiput and frontal 
bone. 

In the acquired form of torticollis, which can be easil) 
righted by manual Force, the head can be retained in a 
corrected position by placing about it a coronet made of 




Plaster of Paris collar. 



plaster of Paris, into which a metal ring is incorporated. 
by means of a muslin bandage passing through the ring 
and about the thigh, traction is made in a direction oppo- 
site to the existing torticollis. This traction is carried 
to the extent of producing a torticollis on the opposite 
side, thereby overcoming the spasm of the affected side. 
For the torticollis of cervical spondylitis a well-fitting 



66 PLASTER OF PARIS AXD HOW TO USE IT 

plaster of Paris corset with a jury-mast from which the 
head is suspended, is the best form of treatment. 

Hip Joixt Disease 

A plaster of Paris spica passing about the lower thorax 
and extending within a few inches of, and at times includ- 
ing, the knee joint, is an effective way of immobilizing 
the diseased hip joint. The spica is not to be applied, 
however, until flexion and abduction deformities have 
been overcome by extension with weights. The presence 
of a large, cold abscess, or sinuses leading into the bone 
or joint, contraindicate the use of a plaster of Paris spica. 




Fig. 



58. Plaster of Paris coronet with ring incorporated to aid in cor- 
rection of torticollis. 



Even if it be desirable to apply some form of brace, or 
traction splint, the plaster spica may be retained when the 
tendencv to flexion and abduction are marked. When 



PLASTER OF PARIS AND HOW TO USE IT 



67 



sole reliance for fixation is placed upon the spica, the 

immobilized, diseased side should be kept from the ground 
by the use of crutches. On the whole, it must be said, 
that the plaster spica, however well applied, is a bulky 
and unclean means of treating hip joint disease, as com- 
pared with some form of metal splint. As a word of 
warning, it should never occur to anyone to apply the 
plaster spica in order to correct a deformity. 

Application of the Hip Spica. — The method of apply- 
ing a plaster hip spica, described in fractures of the thigh, 
are equally applicable in hip joint disease. In addition 
to these, the following will be found useful. The head 





Fig. 59. Application of hip spica in the horizontal position. 

and chest of the patient rest upon a table. Both limbs 
extended, and with the feet resting on another table 
or horse, are grasped by an assistant who exerts traction. 
Another assistant by hooking his hands into the axilla 
exerts counter-extension. With the body thus suspended, 
in the horizontal position, the plaster hip spica can be 
easily applied. (Fig. 59.) 



Kxee Joint Disease 

An effusion of serum or blood in the knee joint, can 
very often be rapidly dispelled by the absolute immobili- 
zation afforded by a plaster cast, investing the thigh, 
including the knee joint, and extending down the leg 
below the calf. A cast of the same extent is necessary in 



68 PLASTER OF PARIS AND HOW TO USE IT 

tuberculous disease of the knee joint, but not until the 
flexion deformity has been overcome by gradual exten- 
sion, with weights and pulleys. The knee joint immo- 
bilized in the cast (of light construction) must not sup- 
port the superimposed weight of the body, therefore 
crutches are to be worn or the knee, encased in plaster 
of Paris, is suspended in the Thomas splint for knee 
joint disease. 

Ankle Joint Disease 

In all affections of the ankle, there is a great tendency 
for the foot to assume a position of equinus combined at 
times with eversion (valgus). To forestall this, the foot 
must very early be placed in a plaster of Paris cast, in a 
position at right angles to the leg. Where there is much 
spasm of the tendo Achilles, this may be overcome by the 
administration of an anesthetic, and if there be still some 
difficulty, a subcutaneous tenotomy must be resorted to 
before applying the plaster cast. 

Flat Foot 

The rigid flat foot, with spasm of the tendo Achilles 
and lack of mobility of the smaller articulations, and 
abduction and eversion in the medio-tarsal articulation, 
calls for a correction which can be maintained only by 
a plaster of Paris dressing. To effect a correction, it is 
necessary to administer an anesthetic and manually force 
the foot into an exaggerated adducted (varus) position. 
It is thus maintained by a plaster of Paris dressing, which 
extends half way up the leg. This plaster cast remains 
on for four weeks. For the first three weeks the patient 
occupies the recumbent posture; thereafter he may walk 
about with crutches. At the expiration of the fourth 
week the dressing is removed and a plaster mold made, 
either from the dressing or directly from the foot. A 
sheet of steel is then hammered to conform to the plaster 



PLASTER OF PARIS AND HOW TO USE IT 6g 

mold, on its plantar surface, as far forward as the head 
of the first metatarsal bone, and to pass obliquely out- 
wards back of the heads of the metatarsal bones, to the 
cuboid, the posterior limit of this splint corresponding to 
the middle of the os calcis. On the inner aspect of the 
cast the splint is hammered out in a semi-ellipse extend- 
ing to the internal malleolus. ( )n the (niter aspect a 




Fig. 60. Lorenz spica for unilateral congenital dislocation of the hip. 

tongue of metal is hammered out as a guide to prevent 
the splint from slipping. This accurately fitted splint, 
thus hammered out over the plaster mold, is placed in 
the shoe, and, acting as a lever, it forces the foot into the 
correct position. 

Congenital Hip Dislocation 

One of the essentials in the successful treatment of a 
congenital dislocation of the hip is the application of a 



70 PLASTER OF PARIS AND HOW TO USE IT 

well-fitting hip spica in which the patient walks about. 
An X-ray picture is first taken as a guide to the location 
of the head of the femur. Then follows a reduction of 
the head into the acetabulum, in which it is maintained 
by abducting the limb. In this abducted position the uni- 
lateral or bilateral spica is applied, according as the dis- 
location has been on one or on both sides. (Figs 60 and 
61.) In addition to the abduction, the limb is slightly 
flexed and rotated in. The spica should preferably pass 
well up on the thorax, though this is by no means abso- 
lutely necessary. It should not extend below the knee, 




Fig. 61. Double spica for bilateral congenital dislocation of the hip. 

in order not to interfere with comfort in walking. The 
plaster cast remains on at least six weeks. At the ex- 
piration of this time it is removed. If a radiograph 
then made shows the head of the femur in the acetabulum, 
the degree of abduction is lessened gradually. All the 
time that the cast is on, the patient walks about, thus aid- 
ing by this pressure, in forcing the head into the aceta- 
bulum and in shaping the latter. After the removal of 
the last cast, a hip splint is to be worn for some months. 



Club Foot 

The deformity known as club foot, if treated immedi- 
ately after birth, and persistently, can be wholly corrected 



PLASTER OF PARIS AND HOW TO USE IT ;i 

by the use of plaster of Paris dressings, within a year or 
two. It is necessary, by a process of manipulations, as in 
modeling, to bring the foot from its equinus position into 
that of a right angle with the leg and to overcome the 
adduction (varus) and inward rotation. When these 
have been corrected a plaster of Paris cast is made to 
invest the foot, extending up the leg to the condyles of 




Fig. 62. Wolff's method of removing wedge from cast to better the 
correction of the club foot. 



the tibia. Great care must be taken in padding the bony 
prominences with non-absorbent cotton to prevent pres- 
sure sores. The best guarantee against decubitus, is a 
thorough reduction of all the abnormal positions that 
occasion the prominences. If the deformity cannot be 
wholly corrected at the first sitting it is remedied after 
the removal of the cast. "With each renewal of the cast 



J2 PLASTER OF PARIS AND HOW TO USE IT 

another attempt is made to better the position of the foot. 
This correction of the very plastic tissues of the new- 
born and of the infant calls for no anesthetic. In adults, 
however, narcosis is necessary. 

Wolff's Method. — The correction is effected under 
anesthesia, and a plaster cast is applied. While this is 
setting, further correction of the deformity is made by 
abducting the foot. Over the outer malleolus and over 
the tuberosity of the head of the first metatarsal bone 
fenestrae are cut to relieve the pressure. At the end of 
the first week a wedge is cut from the outer aspect of 
the cast (Fig. 62), and a linear division made about the 
ankle joint to the inner aspect of the foot. The removal 
of the wedge permits of crowding the foot outwards to 
effect a better correction. For this, and for succeeding 
corrections, rendered possible by enlarging the wedge 
removed, no anesthetic is called for. After each wedge 
cutting from the plaster, and correction, another layer of 
plaster of Paris is applied to hold the foot in its new 
position. When the complete correction of the foot has 
resulted, the cast is covered with strips of basswood 
veneering. These are secured in place by crinolin band- 
ages, and coated with glue. A "water-glass" (silicate of 
soda) bandage is placed over all. The patient is allowed 
to walk about in this dressing for a month or a year, de- 
pending on the degree of severity of the condition. 



PLASTER OF PARIS AND HOW TO USE IT 73 



CHAPTER VII 

Plaster of Paris in Dental Surgery 
All varieties of commercial plaster of Paris will make 
good models, but none other than recalcined plaster, sold 
in the shops under the name of French Dental Plaster, is 
suitable for making impressions. 

Mixing the Plaster 
Place four ounces of water in a bowl, preferably of 
rubber ; but a glazed porcelain bowl will answer the pur- 
pose. It is advisable to have the plaster set as quickly as 
possible, therefore add 
a pinch of salt, alum 
or chlorate of potash. 
If none of these is at 
hand, warm water will 
hasten the setting. The 
addition of a few drops 
of essence of pepper- 
mint to the water will 
dispel the unpleasant 
taste of the plaster in 
the mouth. Take up Fi 
the plaster on an or- 
dinary spatula and sprinkle it on top of the water. Allow 
the plaster to be completely taken up before repeating 
this procedure; and do this a number of times until the 
water has absorbed all the plaster it can possibly take up. 
By following this slow method air bubbles will be pre- 
vented from forming. Then stir the mass with a spatula, 
in one direction only, until it has the consistency of a 
thick cream. Place it in the impression tray (Figs. 63 




63. Dental impression tray 
endentulous upper jaw. 



74 PLASTER OF PARIS AXD HOW TO USE IT 



and 64), which should be previously selected to tit the 
mouth as nearly as possible, so that the minimum amount 
of plaster should be inserted in the mouth. If the im- 
pression is to be taken of the upper jaw, the tray should 

be first pressed up against 
the posterior aspect of the 
mouth, and subsequently the 
anterior part of the tray 
should be pressed into posi- 
tion in front. This will cause 
all surplus of plaster to be 
forced out of the mouth, 
thereby preventing gagging 
or nausea to a great extent. 




Fig. 64. Dental impression tray for 

upper jaw, some teeth being 

present. 



Preparation of the 
Patient 
Gagging, nausea and vomiting may be more certianly 
guarded against by spraying the palate and mouth with 




Fig. 65. Model of hypertrophied jaw. 



PLASTER OF PARIS AXD HOW TO USE IT 



a half of one per cent, solution of eucain or cocain, sup- 
plemented by the internal administration of a drain of 

aromatic spirits oi ammonia. In sensitive patients, the 
best guarantee against nausea, etc., is the injunction to 

have the stomach empty. 

Plaster intended for impressions of the lower jaw 
should be of such thick consistency that the tray may be 

inverted without the plaster falling therefrom. In taking 
an impression where it is impossible to withdraw it in 
one piece, it is desirable to mix with the plaster from one- 
third to one-half of ordinal"}' precipitated chalk. This 
will cause the impression of fracture more readily and 
thus permit of replacing" the parts afterwards, to make 
the model. In the case of cleft palates where a large 
fissure exists, it is advisable, prior to taking the impres- 
sion, to either obliterate the fissure with softened bees- 
wax, or absorbent cotton, or to bridge it over with ad- 
hesive plaster, the buccal surface of which must be oiled. 
The wax and cotton are apt to adhere to the impression, 
but if these precautions are not observed, the plaster of 




Fig. 66. Model of a syphilitic perforation. 

Paris will run up into the fissure, and in withdrawing it 
a laceration of the soft parts may ensue. When the fis- 
sure extends to the soft palate, an impression of the 



76 PLASTER OF PARIS AXD HOW TO USE IT 

hard parts is all that is required, as the posterior portion 
is subsequently modeled in the mouth. 

Difficult Impressions 

Wherever there is a chance that the impression will be 
difficult to remove, as in the case of tumors of the jaw, 
it is advisable to oil the impression tray before placing 
the plaster in it. This will allow the tray to be removed, 
leaving the hardened impression in the mouth, thereby 
permitting the operator to cut it away in sections, which 
can be replaced in the proper position and a model made 
therefrom. 



Impressions for Fracture of the Jaw 

Impressions of a fractured jaw should not be taken in 
plaster of Paris, for modeling composition is far superior 
for this purpose. 




Fig. 67. Model of a cleft palate. 



PLASTER OF PARIS AND HO 



W TO USE II 



Where an operation is contemplated, it is advisable to 
take an impression o\ the month prior to the removal of 
the pathological condition (tumor), as this will serve as a 
guide in making the prosthetic appliance thereafter. 

Making the Plaster Models 

In order to obtain the best models it is absolutely neces- 
sary that the impressions be perfect, that all of these are 
in their proper position before the model is poured. 

Plaster for models should contain the same ingredients 
as for impressions, but it should be somewhat thinner in 
consistency since it has to be poured. 

The Separating Media Between Impressions and 
Models 

To facilitate the separation of the impression from the 
model, a separating medium is necessary, so that one does 
not adhere to the other. Various solutions can be utilized 
for this purpose. A very thin alcoholic solution of shel- 
lac, or water-glass, or ordinary soapsuds, colored with 




Kingsley obturator for cleft palate attached t<> plate 



red ink to thereby indicate the line of demarcation be- 
tween the impression and the model, will answer the pur- 
pose. Oil and vaselin should not be u>L'd, for they soften 

the surface of the model. 



PLASTER OF PARIS AND HOW TO USE IT 



With a earners hair brush, coat the impression with 
any of these separating materials and allow to dry. Then 
soak the entire impression in water of the body tempera- 
ture. The object of this step is to facilitate the flowing 
of the model plaster into at the small crevices, which 
will not happen if the impression is dry. Place a small 
quantity of plaster intended for the model, on the high- 
est portion of the impression, then tap the impression 
gently on the table or with the handle of the spatula, so 




Fig. 69. Kingsley cleft palate obturator covering the cleft. 

that the plaster will flow down into all the crevices and 
depressions. Repeat this as often as is necessary to build 
the models to the desired form. This will prevent bub- 
bles, expel the air from the crevices of the impression and 
eive a most satisfactorv model. 



PLASTER OF PARIS AND HOW TO USE II 



n 



After the plaster has hardened, place the whole in a 
pan of water, and allow it to boil five minutes. The ex- 
pansion caused by the heat will facilitate the separation 

of model from impression. If it is a simple impression 
without undercuts to cause adhesion, merely tapping the 
model with the handle of the spatula will effect the sepa- 
ration. If the separation is hindered, however, by any 
irregularities in the impression,, the latter has to be cut 
away in small pieces until the line of demarcation of the 
separating material is reached. This may be supple- 
mented by occasional tappings with the handle of the 
knife to loosen the parts. 

In making a plaster model from a wax, or modeling 
compound,, impression, as in fracture of the jaw, wet the 
impression, pour the plaster in the same manner, allow 
it to set, place in a pan of cold water and do not boil, 
but merelv heat it until the impression material is thor- 
oughly softened, when it can be easily withdrawn from 
the model. 




Fig. 70. Model of a fracture of the jaw. 



Models should be neatly trimmed and dusted with 
talcum powder, to give them a smooth surface. 



80 PLASTER OF PARIS AND HOW TO USE IT 

Interdental Splints 

The first requisite is to take an impression in wax 
or modeling composition and then to make a plas- 
ter model of both jaws. (Fig. 70.) Then the 
model of the fractured jaw is so cut and replaced 
on an appliance for that purpose, known as an ar- 
ticulator (Fig. 71), as to bring the teeth of the up- 
per and lower jaw in normal occlusion. On these 
models the model of the interdental splint is made in 
wax, and from this it is made in vulcanite (Fig. J2) or 
cast in pure tin. It is advisable to paint the cusps of the 
teeth on the models with several coats of shellac or to 
burnish over the cusps with No. 60 tin foil. The object 
of the latter procedure is that the indentations in the 
splint shall be a trifle larger than the teeth in the mouth, 
thereby permitting the reduction of the fracture more 
readily when the splint is inserted. 




Fig. 71. Model of a primitive articulation in plaster. 



If it is a difficult or painful procedure to insert the 
splint in the mouth, and reduction is possible forthwith, 
an anesthetic is administered to relax the muscles. 
When reduction is not possible at the first sitting, the 
splint may be inserted and a tight Barton's bandage 
placed about the head. In a few r days normal occlusion 
will thus be attained. 



PLASTER OF PARIS AND HOW TO USE IT 



81 



Plaster Models of ihk Bod* 

When the impression is to be made of a complicated 
part of the body, as a foot or hand, it is desirable to make 
it in two sections, and, furthermore if the part be covered 
with hair it had better be anointed with vaseliri to pre- 
vent the plaster of Paris from adhering. The plaster 
for the first half of the impression may be of firm con- 
sistence and spread upon a layer of gauze. This half ap- 
plied, the remaining surface of the part and the corre- 
sponding surface of the half of the impression that has 
been applied, are coated with a separating material (col- 
ored soapsuds., shellac or water-glass), and then the plas- 
ter of thinner consistence is poured over until it covers 
the part completely. When the plaster is set the impres- 
sions are separated. A model is made by tying the halves 




Fig. 72. [nterdental splint with fenestra in the center for feeding. 



82 PLASTER OF PARIS AXD HOW TO USE IT 

of the impressions together after coating their inner sur- 
faces with separating material (applied with a camel's 
hair brush), and then a thin cream of plaster is poured 
into the interior of the impression, into the furthest, end of 
which a perforation is made to permit the escape of air, 
thus to avoid the formation of bubbles. 



Repair axd Preservation of Models 

Any broken model may be repaired with cement. 
Models may be prepared for preservation by boiling in a 
solution of alum, and then coating when dry, with shellac. 
Plaster Impressions and Moulages of Skin Diseases 

To make wax models (moulages) of skin lesions, an 
impression is first made in plaster of Paris. This im- 
pression, when hard, is moistened in hot water, and then 
a mixture of melted beeswax, and spermaceti, equal parts, 
is poured on the impression. The wax model is easy 
to separate from the moistened impression. The coloring 
is subsequently imparted to the wax model with 
pigments. 



INDEX 
A 

PAGE 

Adjuvants, Chemical 7 

Alum 7, 11 

Salt 7, 11. 19 

Ambulatory Cast 32 

Application of Plaster 8 

B 
Bandages, Plaster : 

Commercial 3 

Hand-made 2 

Wire 3 

Bavarian Splint 41 

Braatz's Splint 51 

C 
Cast : 

Ambulatory 3 2 

Removal of 1 1 

Replacement of T 4 

Splitting of 1 7> T ^ 

Cole's Splint (Sugar-tong) 49 

Colles' Fracture - 1 

Collar Plaster 63 

Containers, Tin 3 

Club-Foot : 

Woolf-s Method 72, 73 



84 



INDEX 



PAGE 

Corset •- 54 

Bradford Frame 60 

Goldthwait Method 60 

Horizontal Method 60 

Trimming of ^6 

Vertical Method 54 

Cuff 10 

D 

Dental Surgery j^ 

Dental Plaster j$ 

Mixing Plaster 73 

Tray Impression 73. 74 

Dextrine Bandage 1 

Disease : 

Hip Joint 66 

Knee Joint 67 

Ankle Joint 68 

F 

Fiat-Foot 68 

Fractures : 

Ankle Joint 29 

Carpal Bones 2$ 

Colles' 21 

Elbow Joint 21 

Femur 1 Shaft) 28 

Foot 31 

Forearm 19 

Humerus 20 

Hip-Joint 2? 

Jaw 80 

Metacarpal 23 

Olecranon Process 34 



INDEX 

PAGE 

Patella 33 

Thumb j j 

Tibia 29 

Fraying- of Bandage 6 

G 

Gigfi-Saw 1 1 

Gutter Splint 52 

H 

Hemp-Splint 43 

Hip-rest . 26 

Hip: 

Fracture 25 

Joint Disease 66 

Spica 67. 25. 2~ 

T 

Jacket 54 

Jury Mast 58 

L 

Lorenz Bed 63 

Lorenz Spica 69 

M 

Massage 8 

Materials 

Cotton 

Crinoline 

Deimel Mesh 

Dextrine 

Flax 

Flannel 

Gauze 

Hemp 



86 INDEX 

page: 

Jute i 

Muslin i 

Sail Cloth I 

Straw i 

Tricot I 

Mitre Saw 13 

Molded Splints 38 

Model, Plaster : 

Cleft Palate 67 

Fracture of the Jaw 70 

Hypertrophied Jaw 65 

Making of yy 

Preservation 82 

Repair of 82 

Separating Media yj 

Syphilitic Perforation 75 

Moulages 82 

P 

Paralysis, Ischemic 18 

Plaster Bandage : 

Continuity 9 

Fractures . . 16 

General Considerations 16 

Precautions 8 

Removal of 24 

Sections 9 

Posture 18 

Protection Skin 7 

Soiling 4 

R 

Refuse, Disposal of 15 

Removal Bandage 15 

Removal Plaster it 

Sugar 15 

Salt 15 



INDEX 



p \(.i 

Saw : 

Gigli i i 

Mitre [3 

Sections — Plaster 9 

Shears, Stilles [3 

Spica : 

Hip 67, 25 

Lorenz 69 

Thumb 23 

Splints: 

Ambulatory 32 

Bavarian 41 

Rraatz's 51 

Compound 34 

Fenestrated 31 

I hitter 52 

Heated 36 

Hemp 43 

Interdental So. 82 

Molded . 38 

S gmented 35 

5i gar-tong 40 

Suspended 36 

Tricot 44 

T 

Torticollis 64 

Trie- • - 29 

Splint 14 

Trimming Corset 5 fl 



Veneering 34 



88 INDEX 

W 

PAGE 

Wire Bandage 3 

Wolff: 

Club-foot 70, 7 1 

X 

X-Ray : 

Fractures 16, 24 

Congenital Hip 69 

LOFC 




JAM 14 M 



